Benign growth of the prostate, often known as BPH, which in fact stands for benign prostatic hypertrophy is an almost ubiquitous feature of the aging male. Most men from middle age will start to suffer some increase in the size of the prostate. For some men, that will start to cause urinary symptoms, thanks to that growth, causing a progressive obstruction to the flow of urine out of the bladder. Those symptoms can vary from those relating to the flow – that is a slow stream, hesitancy initiating that stream, or a sensation of poor bladder emptying – or those symptoms relating to the storage of urine in the bladder, which can often cause the most bother – is getting up at night to pass urine, leading to sleeplessness and mood irritation – to the urgency that is unable to hold on and having to rush to the loo, or even leakage before getting there, and also just simply frequency in needing to go to the loo very frequently during the day.
These symptoms can affect up to 60% of men aged 60, although only a minority ever seek help in terms of receiving treatment, and the subsection of that goes on to have surgical intervention.
When advising a man regarding his bothersome waterworks symptoms that are thought to relate to the benign growth of his prostate and obstruction to the flow of urine out of the bladder, initially, one looks to employ conservative measures – essentially fluid management. Reducing caffeine intake and alcohol intake can help with the very bothersome symptoms that relate to the storage of urine – that is frequency, urgency, and getting up at night to pass urine. But beyond that, if these conservative measures don’t help, one can also employ approaches such as pelvic floor exercises and bladder training techniques, then you start to look at the option of medical therapy usually in the first instance. The classic first tablet to try would be that of an alpha-blocker, usually, tamsulosin, which looks to relax the smooth muscle within the prostate and then the neck of the bladder to decrease obstruction to a degree and hopefully improve symptoms. These tablets are well-tolerated with minimal side effects and, if effective, are taken in the longer term.
Further tablets taken to shrink the prostate can be added to this, or indeed used as monotherapy, such as finasteride or dutasteride. If the tablets don’t work, aren’t tolerated, or worked for a while and then the symptoms returned over time, then the next step in treatment is surgical intervention. Interventions range from those that are considered more invasive to those that are less invasive. The more invasive ones, on the whole, look to remove tissue to core out the prostate, if you like, to maximize this obstruction and maximize the likely improvement and symptoms, both in terms of the flow of urine and those related to storage. Less invasive options look to improve symptoms but have lesser side effects and a quicker recovery.
On the whole, medication is well-tolerated. The alpha-blockers may have side effects, including those relating to headache, blocked nose, and dizziness, and some men can also describe developing dry ejaculation. Finasteride or dutasteride, the 5-alpha reductase inhibitors can have a deleterious effect on sexual function in terms of libido and loss of erectile function. In terms of surgical interventions, the standard, more invasive surgery is where you remove tissue such as a TURP, holmium laser enucleation of the prostate, or green light laser will improve your symptoms reliably, but also represents somewhere between a 40-70% chance of leaving you with permanent dry ejaculation, and a small figure of probably less than 5% of affecting erectile function.
The less invasive approaches such as prostatic urethral lift procedure using UroLift implants, whilst it’s less effective in terms of the level of symptom improvement, have essentially a zero percent chance of affecting your sexual function.
Other newer, less invasive approaches such as Rezum have about a 10% risk of giving you permanent dry ejaculation, and an even newer device called iTind has similar type figures…